Provider Demographics
NPI:1053841726
Name:STENSRUD, KELLY A (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:STENSRUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1529 FULLER LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4211
Mailing Address - Country:US
Mailing Address - Phone:651-757-7656
Mailing Address - Fax:
Practice Address - Street 1:637 KINGSBOROUGH SQ STE E
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4944
Practice Address - Country:US
Practice Address - Phone:757-410-2804
Practice Address - Fax:757-410-2824
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant